Cement augmentation of intertrochanteric fractures stabilised with intramedullary nailing
Introduction
Lately, the incidence of proximal femoral fractures has substantially risen in the elderly.9, 13, 14, 15, 22, 40 This rise has been attributed to an increase in their life span and the underlying poor bone stock and osteoporosis.19, 29 It has been estimated that by the year 2040 the incidence of these fractures in the elderly will have doubled and this would cause a great burden on the national health care systems.8, 33
Due to the poor bone quality the vast majority of these fractures result following a simple fall.6 Fixation of proximal femoral fractures with a sliding screw plate or nail remains the gold standard of treatment.7, 26, 27, 30, 31 The latest generation of implants are considered more elastic and have a lower rate of complications due to their mechanical characteristics and controlled telescopic movement for the fracture impaction during weight-bearing.
One of the main reason for revision surgery which has been reported to be as high as 16% is the cut-out of the fixation device at the apex of the femoral head.1, 23, 24, 25, 32, 34 Several internal fixation techniques have been developed to avoid this complication such as double or convergent screws. Recently, augmentation of the weak bone with PMMA or calcium phosphate cement has been studied in vitro and in clinical trials. Augmentation was facilitated by injecting the cement or the bone substitute at the level of the neck of the femur. Whilst augmentation is considered as a useful method with regard to the increase purchase between the bone and implant interface, drawbacks have also been discussed including the development of thermal necrosis and impaired fracture healing due to the exothermic reaction induced by the cement material.19 Furthermore, removal of the cement might by a problem in cases where revision surgery would be necessary.2, 17, 21, 23 Despite the above concerns, experimental trials on human cadaveric proximal femurs augmented with a low viscosity PMMA bone cement have demonstrated that loading the femoral head in a physiological manner beginning at 1500–4000 N caused head displacement for non-augmented implants in all the cases studied, whereas 50% of the augmented implants did not fail.11, 18, 19, [42] These experiments have suggested that the augmentation method enhances the implant anchorage in osteoporotic bones.
The aim of this prospective randomised study therefore was to evaluate the clinical and radiological results of a cement augmentation method of internally fixed unstable intertrochanteric fractures in osteoporotic elderly patients compared with the conventional internal fixation without any augmentation.
Section snippets
Materials and methods
The study was performed between January 2006 and March 2010. We treated 80 patients (24 males, mean age 84 (80–94) who sustained unstable trochanteric fractures (A2.1, A2.2, A2.3, A3). Inclusion criteria were an unstable trochanteric fracture, defined as fracture with three parts or more, age more than 80 years and a Singh score of 1 or 2.36 Exclusion criteria were dementia, neuromuscular or musculo-skeletal deficiency which could limit the ability to perform objective functional tests,
Results
In group A the average HHS score before the fracture was 56.49 (range 19–89), 48.2 after 1 month post-operation (range 17–88), 54.28 after 3 months (range 25–88), 54.71 after 6 months (range 27–87), and 57.91 after 12 months (range 29–88) (Table 1). In group B the HHS score before fracture was 56.75 (range 20–89), 49.31 after 1 month (range 18–87), 53.56 after 3 months (range 24–87), 56.42 after 6 months (range 29–88) and 59.86 after 12 months (range 32–89) (Table 2).
Analysis of haemoglobin and
Discussion
The management of unstable trochanteric fractures is challenging to the most experienced trauma surgeons. Surgery may be delayed due to associated co-morbidities and peri-operative complications could not be underestimated in this cohort of patients. Moreover, the poor bone stock frequently seen in these patients may compromise the mechanical environment of the fracture.
The degree of underlying osteoporosis was evaluated from the pelvic AP radiographs by assessing the Singh index. We did not
Conclusion
Implantation of PMMA cement for augmentation of the sliding screw during fixation of intertrochanteric fractures appears to be a safe method with good clinical outcome. It allows patients to have a faster rehabilitation and a shorter period of hospitalisation. Further larger scale studies will throw more light into the efficacy of this technique and the health economic benefits to the society and each individual health care system.
Conflict of interest
The author did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from commercial entity.
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2021, Journal of Clinical Orthopaedics and TraumaCitation Excerpt :The postoperative range of motion of the hip was not described in these studies. Two intraoperative complications related to cement augmentation were described, including a little amount of cement extravasated into the hip joint without clinical problems for the patient,32 and cement leakage into the joint30 with exclusion from the study of this patient. A third intra-operative complication reported20 was unrelated with the cement injection.
Is bone-cement augmentation of screw-anchor fixation systems superior in unstable femoral neck fractures? A biomechanical cadaveric study
2019, InjuryCitation Excerpt :Gupta et al. showed no intra- or postoperative complications in augmented SHS systems with good functional results (Salvati and Wilson score) after 18 months [38]. However, augmentation did not generally improve patients’ functional capacity [15,16,39], although it may have the potential to prevent reoperations by strengthening the osteosynthesis construct [16]. The bone mineral density of our specimens was comparable to tested femora in other publications (0.8 g/cm2; T-Score: -1.5) (Table 1, Fig. 5) [20,30], and 16 of the 20 specimens had values more than one standard deviation below the mean gender peaks for young men (0.98 g/cm2 ± 0.12 g/cm2) and women (0.92 g/cm2 ± 0.10 g/cm2) [40].